NY mental health chief Michael Hogan has come clean in an almost doomsday scenario for people with the most serious mental health conditions. In "Integration of Mental Health Care", Hogan compares what we face ahead to the deinstitutionalization efforts of the 1970s and 80s, which lead to great increases in homelessness of people with mental illnesses and others depending only on meds and an SSI check....  only worse. (Hogan also led efforts to complete the New Freedom Commission Report, on transformation.)

The best report I've seen on these dangers is from the Kaiser Health Foundation, "MEDICAID POLICY OPTIONS FOR MEETING THE NEEDS OF ADULTS WITHMENTAL ILLNESS UNDER THE AFFORDABLE CARE ACT".  It raises concerns I discussed in an article for "Voices for Change", in summary:  1) Health  reform will leave behind many of the people with the most serious and persistent mental health needs, 2) we are turning back to a medical model, where psychiatric rehabilitation is secondary.  Here are 2 very important passages from the Kaiser report:      

"Many people in this [homeless] population have experienced tenuous or negative interactions with public programs; they often lack a permanent address, which complicates Medicaid enrollment and renewal processes; and they are often in an age cohort (mid 50s) where their health problems are beginning to manifest. This could potentially place large demand on nursing home services which are often the only long-term option for ill individuals without other housing available."

"However, there was also consensus that benchmark coverage is not likely to provide the full scope an intensity of benefits needed by those with more
severe illnesses, such as schizophrenia or bipolar disorder. These individuals will have needs similar to those who currently qualify for Medicaid due to a psychiatric disability and are likely to require many of the unique services covered by traditional Medicaid coverage to meet the needs of low-income
individuals with severe mental illness, such  as intensive case management, crisis intervention, and psychosocial support services. Participants also noted the importance of the rehabilitative services option available to states under traditional Medicaid(the “rehab option”) in providing many services needed by those with severe illnesses. The flexibility allowed under this service category enables states to finance a range of psychosocial services, such aspeer specialist counseling, family psycho-education, and supported employment . The group noted that lack of access to the full range of support services for newly eligible individuals with severementalillness could lead to increased burden on inpatient care units or public mental health systems due to unmet need."

So Hogan in "Integration of Mental Health Care" is going with a faith-based approach, which may be what we all need subject to a strong economic turnaround.  As he states

 "And everyone from patients to payers wants care to be "integrated." So now we have to figure it out... about the only thing we can be certain of is that no external force will solve these challenges for us. And we must have faith that quality work and diligent advocacy will be recognized."

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Well, there seems be no argument that the quality of public mental health (MH) services is poor.  This is why the President's New Freedom Commission report on Mental Health (2003) stated that "reform" was not enough, but "[t]o improve access to quality care and services, the Commission recommends fundamentally transforming how mental health care is delivered in America." (p. 4).  So can we get mental health transformation and health reform to co-exist, or even enhance the other? 
I really think that the jury is out here. Here is in part why- there are both “no” and “yes” answers.

No 
Health reform starts with health insurance for everyone. Health insurance approves care that is “medically necessary.” Medical necessity generally equals “medical care”. That often leaves out  vocational supports (eg., supported employment) and housing supports (eg., housing first). For many people with MI (such as myself), these supports are essential to recovery.  
 
Yes
One goal mental health transformation shares with health reform is a movement towards patient-centered care. The mental health care that I've seen as a consumer and evaluator continues to not be patient-centered.  A challenge is that there are several iterations of "patient-centeredness" that need to be addressed. So we can start of by saying that a patient should receive care that aligns with his/her specific needs and preferences. 
 
          *This is care that is not  disease centered, diagnosis-centered or program centered care. For example, with patient-centered care, a day program client would not hear from staff: "I cannot discuss this issue with you, you must work it out in the group." And I should not hear, as I did a few years ago from a new psychiatrist,: "Since you have bipolar disorder you really need to be on a mood stabilizer (ie., Lithium), and definitely when you are on an antidepressant, even if you’ve lived without it for a long while."  It didn't matter that I had been off mood stabilizers for almost a decade, and lead a relatively non-troubled and productive life, with other supports in place.

          *The next iteration is active client participation (eg., shared decision making), very important with
psychiatric patients who tend to be passive recipients of care… more on that at a later date.
 

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This morning I attended  "Beyond Parity:Mental Healthand Substance Use Disorder Care under Payment and Delivery System Reform in Massachusetts", an excellent series of presentations and discussions sponsored by the Mass. Health Policy Forum, along with the Mass. DMH and the Blue Cross Blue Shield foundation. Colleen Barry, Phd, of Johns Hopkins, presented an excellent report on the topic at hand.  This payment oriented report complemented nicely our report with the Heller School on the stakeholder identified coverage and policy issues of care integration. 

It's clear from both these forums a significant issue is trust... within and among providers, consumers, state policy leaders.  The idea is that with massive change, stakeholders will have to give something up in order for the system to move forward, and then they get their return.   Requires alot of trust, and probably not enough at this point.  Too much at stake in the short term.

Another underlying notion is the state of our economy.  My feeling is that the challenges we are facing are not just about behavioral health, but about the health system at large, the social services system, and the justice systems...as well as the impact of a poor economy on citizens, taking us right back to reduced behavioral health. Solutions not at all clear.

I must say that I do like and appreciate representative Walsh's optimism and can do approach. I like working that way even in the face of high multiple barriers.  Rep. Walsh's perspective is that health reform will provide the system with efficiencies that will allow servies to thrive.  Th
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The October 17th edition of Mental Health Weekly, in a fairly extensive piece, has reported on   Behavioral Health and Health Reform summit and report, noted in my October 14th posting. (I'm going to try to get permission for posting on this site).  Vic DiGravio of the Association for Behavioral Healthcare, Mass. DMH Commissioner Barbara Leadholm and I are all quoted. 

 According to the article, the Bottom Line is "Education, vocational, housing and peer supports, important components to recovery. should be considered in efforts to improve integration."

In addition, the report highlights our 12 major themes:

 1. Coverage expansion does not automatically translate into optimal access or quality of care.

2. Integrating behavioral health and general health care at the state level is essential.

3. New models for integrating care hold promise for improving behavioral health care.

4. Health reform implementation must be accompanied by increasing the use of evidence-based practices.

5. Health care integration benefits greatly from the use of health information technology.

6. Integrated care brings changes to financing and payment mechanisms.

7. Effective care coordination is a critical aspect of behavioral health integration .

8. Workforce development is vital to the delivery of quality behavioral services in integrated, team-based models of care.

9. Outreach to hard-to-reach populations is critical.

10. Peer specialists are vital contributors to integrated care teams.

11 . Person-centered planning is essential to recovery.

12. Health reform implementation must take account of housing needs of people with behavioral health conditions.

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"Impact of Health Care Reform Law" is an article I wrote that originally appeared in the Winter/2011 of "Voices for Change",  a publication of the Transformation Center, the statewide mental health consumer run organization in Massachusetts.  This article explains my major concerns with health reform's impact on on mental health services.

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In collaboration with the Heller School at Brandeis University and Consumer Quality Initiatives, Reservoir Consulting Group is releasing an important report: HEALTH REFORM AND BEHAVIORAL HEALTH SERVICES IN MASSACHUSETTS: PROSPECTS FOR ENHANCING INTEGRATION OF CARE
I believe that this is the first report assessing the impact of health reform on behavioral health services comprehensively, bringing in the perspectives of a variety of stakeholders, and focusing on the state that is the earliest adopter of health reform, Massachusetts. The Summit that generated this report was funded in part by the Robert Wood Johnson Foundation Community Health Leader award I received in 2008.

My own top 3 takeaways from the report are:

            -Expansion of health insurance coverage does not automatically translate into improved health services access for people with serious mental illnesses, and could result in a reduction in the provision of important psychosocial services(eg, vocational supports)
            -The primary care workforce will need to be educated on the delivery of quality behavioral health services, in a team based fashion that encourages client participation 
            -People with serious mental illness and addictions often do not utilize health services due to their high rates of poverty, homelessness, trauma, immigrant status, and transportation barriers. Integrated health teams will need to provide services within their groups’ respective communities in order to provide them with good care.







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Post Title. 10/12/2011
 
Welcome to my first post. 
I am a mental health consumer researcher and evaluator in Massachusetts, and up until recently was the Executive Director of Consumer Quality Initiatives, www.cqi-mass.org, where you can see alot of my past work.

To summarize, although a supporter of health reform generally, I am concerned that reforming through health insurance expansion will hurt consumers with the greatest meeds. For example, health insurance typically does not cover vocational supports or housing supports.  In fact, direct service funding from state government for those services may decrease as more people are insured and a greater amount of medical services are covered.

In the near future, I will be sharing with you the reports of myself and others on health reform and mental health. 

I look forward sharing and interacting.

Jonathan Delman, MPH, JD, PhD (cand.)
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